Radiology Corner – What Are These Peculiar Calcifications?

By: Terry R. Yochum, DC, DACBR, Fellow, ACCR and Michael S. Barry, DC, DACBR

Figure 1.

Figure 1.

History

This eight-year-old patient presents with a history of scoliosis and back pain. Where and what are the peculiar calcifications? Are these symptom-producing lesions? (See next page.)

Diagnosis

Childhood idiopathic intervertebral disc calcification.

Discussion

There are two forms of disc calcification, apparently based on age. They are childhood and adult.1

Childhood Idiopathic Intervertebral Disc Calcification. This is a peculiar clinical and radiological phenomenon. The age of onset is usually between six and twelve years of age, with male involvement being twice as common. The etiology is unknown, but trauma, infection, inflammation, and other factors have all been implicated. The most common site affected is the cervical spine, followed by the thoracic spine, and, least commonly, the lumbar spine. Usually, only one disc is involved, but there may be multiple involvement in up to 30% of cases.1,2

The calcification is distinctively located within the nucleus pulposus and not the annulus fibrosis. Prolapse of the calcified nucleus may occur, but usually is not associated with neurological symptoms. Linear or computed tomography does not add significant supplementary information, though computed tomography (CT) should be obtained if neurological complications are present.1–3

Figure 2.

Figure 2.

Clinically, a spectrum of presentations occur. Approximately 70% of these patients will have pain, 30% an associated fever, and 4% neurological symptoms. Up to 15% will remain totally asymptomatic. Other associated findings include neck stiffness and simulating meningitis, localized tenderness, scoliosis, elevated erythrocyte sedimentation rate (ESR), and leukocytosis.3,4

The radiographic features are distinctive. The calcified nucleus pulposus appears with a flattened oval or rounded opacity within a mildly widened intervertebral disc space. The opposing surfaces of the contiguous vertebral bodies are flattened in contour. The most unique features of this syndrome are the self-limiting nature of the symptoms and the close temporal relationship with the apparent reappearance and disappearance of the discal calcification. Usually, the symptoms subside within several weeks to months with only supportive pain control methods. Observation of the discal calcification will also demonstrate gradual resorption and fragmentation over the same coinciding periods. No serious residual deformity or impairment is to be expected; however, persistence of isolated vertebral body flattening and premature loss of the disc height with osteophytic formation, coinciding with the level of previous calcification, may be expected.2,4

Adult Idiopathic Intervertebral Disc Calcification. This is most likely degenerative in nature, but lacks the associated radiographic features of osteophytosis, endplate sclerosis, and loss of disc height. Clinically, these are asymptomatic unless associated with discal herniation.1,4

In association with disc degeneration, calcification within the nucleus pulposus and annulus fibrosis is a commonly identified radiological finding. These discal calcifications are visible in association with other signs of degenerative joint disease, including loss of disc height, endplate sclerosis (eburnation), and osteophytes. Nuclear calcification may assume a rounded, flattened, or oval configuration, or be fragmented and even linear. Most commonly, the oval contour is apparent with evidence of fragmentation. Calcification within the annulus fibers is a far more frequently observed finding in degenerative disc disease (osteoarthritis). These are usually visible at the anterior aspect of the disc, especially in the lower cervical spine. Less commonly, they may be apparent at the lateral margins of the disc space. The calcification characteristically is less than 2mm thick, vertical, slightly curvilinear, and usually not continuous with the adjacent vertebral body margins. These annular calcifications have been called “intercalary bones,” and at times may simulate syndesmophytes (inflammatory spurs) seen in ankylosing spondylitis.1–4

References

  1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 2nd ed. Baltimore, MD: Williams & Wilkins, 1996.
  2. Ginalski JM, Landry M, Gudinchet F et al. Is tomography of intervertebral disc calcification useful in children? Pediatr Radiol 1992; 22:59.
  3. Furukawa K, Hoshino R, Hasue M et al. Cervical intervertebral disc calcification in child. Case report with 7-year follow up. J Bone Joint Surg (Am) 1977; 59:692.
  4. Yochum TR, Albers VL. Childhood idiopathic disc calcification [Radiology Corner]. ACA J Chiro 1981; Feb.

About the Authors

Dr. Terry R. Yochum is a second generation Chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is a Diplomate of the American Chiropractic Board of Radiology and served as its vice-president and president for seven years (1983–1990).

Dr. Michael S. Barry is a 1988 cum laude graduate of Palmer College of Chiropractic. He completed a three-year radiology residency at Logan College of Chiropractic following two years of clinical practice in Las Vegas, Nevada. He received his diplomate in radiology from the American Chiropractic Board of Radiology in 1992.